GW1--06060_Well Construction - GW1_20230921

ALL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well ConhactorInformation: -
.}CCri lJ.)c.+,�1c9Y1.5 S14x:WATEItZONFS':•'"':'"- . . - - --- ------._
FROM TO DESCRIPTION
Well ContraetorName � ft 260, ft 2 errs
ayg3/./1 ft. ft i
NC Well Contractor Certification Number •--
;e15:OUlEitCASING(furmulti=eased'wells)`,OItIIlVE12'tif'ap'llcable) ;_1 -
-
Yadkin Well Company, Inc. . FROM TO DIAMETER _ THICICNESs MATERIAL -
ft. ft. in.
Company Name
�/1/�f� (� 'i T6:IIQI2:NECASING'OR TT1B]NG(ge'othermal closed=Inop];�t,_".`,:f.'_:=`_:'Y':�::'_I-.;
2.Well Construction Permit it: • ee v Tl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,County,State,Variance,etc.) 4- /ft• 1 i®1J ft• 6/y in- 5OR P l/c
• G ft. ft in.
3.Well Use(check well use): E
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS , MATERIAL LI,�
❑Agricultural ❑Municipal/Public ft ft in.
OGeothermal(Heating/Cooling Supply) Pm'esidential Water Supply(single) ft ft. in.
o
❑Industrial/Commeicial ❑Residential Water Supply(shared) 18 GROUT ': __._._-. __._- _—
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT F.
Non-Water Supply Well: [g1 ft. ,2 0 ft, fc lelI Poem, t 1645 s
OMonitoring ❑Recovery U ft. ft �'t
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
1 19:SMW((PRAVFSLPACIC'(if ap'plicatile) _ ";.=—
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMZNTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
OGeothermal(Closed Loop) ❑Tracer 205DRTT1'TNGZOG"(a'ttactin`dditional`sheetsid•ices'sary')1_`•`-_:p="4-_=:�:_
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,eta)
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks)Date Well Started 'IIslas D ft 2 ft. 5.®•t
4.Date Well(s)Completed: Si WI Well ID#AA P'-1 7+ 2 R' 95 ft Sa vt CIs4 o Ar
5a.Well Location: 4 a,�dm( Phone#: ' 3�8�(a 3 3 �� ft. 4 22 ft
ii:e.j;alr( Rvtoe. ft ft. - ..
Facility//-O�wnerNName ''� f Facility lD#(if
faapplicable) ®� ft. ft • `;"� 1:-..! �/ �a«.1
f 9f ON V ; SeRI r'e� /� s1- , e ft. ft. SEP r 202"
Physicall Address,y City,and Zip •`,if,'g /5� ft. ft. ^
_ _.1 .f-q!" d at .��ls��',dl 7:�21.:RF.MARTCSIZ:Zf .z:.:'1 z: '"X`j e,'."`:. 1;e 114.5 :-..'" .n:',n_r^ .,,,"...yfl-l-trrA_
County a Parcel Identification No.(PIN) �raL'7-� �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) - 22.Certification:
36 0 , V 13 CN g J 1/ 1<4�l'31'o o w
� � _ (t� 03
6.Is are well(s): Permanent or OTemporary Signature of ertified ell Contractor a Date
( )the well()
By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes pr ArYp ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the'same You may use the back of this page to provide•additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I1GW--1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1 24.SUBMITTAL INSTRUCTIONS
L,
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Qa 200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: SO (ft,) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" •
11.Borehole diameter: (iO (in.)Bit Off: 6,601 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC�27699-163 6
12.Well construction method: 1 24c.For Water Supply and Open-L'oop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) P county environmental health department of the county where installed
• FOR WATER SUPPLY WELLS ONLY: Pr
24d.For Water Wells producing I over 100 000 GPD: Co
py opy to DWR,CCPCUA
13a.Yield(gpm) s h Permit Program,1611 MSC,Raleigh;NC 27699-1611 • 8
G Method of test:
70% hth pDate Site Visited: 3 --I--,..3 1
13b.Disinfection type: Amount: F 1 OZ Site Visited By: v a ' t
Form GW-1, . North Carolina De artment of Environmental Quality-Division of Water Resource , Revised 6-6-2018 --1Price. I 'II